The purpose of this K23 proposal is to provide Jenny Shen, MD, MS with the protected time and resources to pursue the training needed to become an independent patient-oriented researcher. Dr. Shen is a board- certified nephrologist with a Master's Degree in Epidemiology. Her research focuses on improving outcomes in patients receiving dialysis, particularly those from racial and ethnic minorities. Cardiovascular (CV) disease is the leading cause of death among patients on maintenance dialysis. While CV medications are a mainstay of treatment, the evidence for their effectiveness in this special population is conflicting. We hypothesize that differences in the trajectories of longer-term adherence to CV medications might explain the variation seen in clinical outcomes for dialysis patients prescribed CV drugs. We propose to determine which trajectories of adherence are associated with the best outcomes and to understand why these different trajectories exist. Our study has three specific aims: 1) to identify trajectories and correlates of longer-term adherence to CV medications in patients initiating dialysis; 2) to assess the relationships among different trajectories of longer-term adherence to CV outcomes in patients receiving dialysis, and to test if these relationships are modified by race and ethnicity; and 3) to describe and compare the experiences, knowledge, and beliefs about longer-term medicine-taking over time and across various racial and ethnic groups receiving dialysis. We will use data from the U.S. Renal Data System, including Medicare Part D prescription claims data. Aim 1 will employ an innovative method of group-based trajectory models to classify patients by their pattern of adherence to CV medications in the first year after dialysis initiation. Aim 2 will use multivariable time-to-event analyses to assess the association between the different patterns of adherence and CV events. Aim 3 will involve serial semi-structured interviews conducted over the course of the patient's first year of maintenance dialysis. Results from the proposed work has the potential to decrease the burden of CV disease in the dialysis population by informing the creation of culturally competent interventions aimed at improving longer-term adherence to CV medications in racially and ethnically diverse populations of patients undergoing dialysis. It will also utilize te resources of the UCLA Clinical and Translational Science Institute to provide the mentored training and experience in advanced quantitative methods of longitudinal data analysis, qualitative research methods, and health services research focused on minorities that will enable the applicant to successfully become an independent, patient-oriented researcher.